Intra-Abdominal Tumors and Cysts:
- Intra-abdominal tumors and cysts are abnormal growths found within the abdominal cavity. These can originate from various organs.
- Tumors or cysts formed within abdominal cavities, such as the peritoneum, mesentery, or retroperitoneal space, are treated with surgical procedures like excision or destruction.
Removal Methods:
- Excision
- Destruction
- Ablation
- Cauterization
- Cytoreduction
- Debulking
- Other tumor/cyst removal methods
New codes for 2025:
Effective January 1, 2025, five new codes were added for Excision or destruction of intra-abdominal tumors. The old CPT codes were deleted.
Coding guidelines:
- Codes 49186, 49187, 49188, 49189, and 49190 describe excision or destruction of intra-abdominal primary or secondary tumor(s) or cyst(s) via an open approach.
- These procedures include cytoreduction, debulking, or other methods of removal of the tumor(s) or cyst(s).
- Codes are reported based on the sum of the maximum length of each tumor or cyst excised or destroyed (eg, ultrasound desiccation). Only the tumor(s) and cyst(s) are measured, not the tissue (eg, mesentery) in which the tumor(s) and cyst(s) may be implanted.
- If only a portion of a tumor or cyst is excised or destroyed, then only the excised or destroyed portion is measured.
- Only the size of the tumor(s) or cyst(s) should be measured for CPT coding, not the margins or surrounding tissue.
- Open resection of recurrent ovarian, endometrial, tubal, or primary peritoneal gynecological malignancies without lymphadenectomy should be reported with 49186, 49187, 49188, 49189, 49190.
- All other open resection of initial or recurrent ovarian, endometrial, tubal, or primary peritoneal gynecologic malignancies should be reported with 58943, 58950, 58951, 58952, 58953, 58954, 58956, 58958, 58960.
Procedure Documentation Guidelines:
- The tumor(s) and cyst(s) should be measured before excision or destruction.
- Procedure code selection is based on the size of each tumor removed; hence, the preoperative measurement must be documented for each tumor.
Example:
- A left retroperitoneal mass (A) measuring 5 cm was identified and resected. In addition, three different tumors (B, C, and D), each measuring 1 cm in the retroperitoneal mesentery, were identified and resected using electrocautery.
Code Selection:
- Sum the size of each tumor: 5 +1+1+1 = 8 cm.
- Bill the code 49187 (the sum of the maximum length of tumor(s) or cyst(s) is 5.1 to 10 cm).
- The measurement includes only the tumor(s) and cyst(s), excluding the margins.
Reimbursement Guidelines:
2025 National Physician Fee Schedule Relative Value File January.
MPFS Status Indicator:
- A: Active Code These codes are paid separately under the physician fee schedule if covered.
- A/B MACs (B) remain responsible for coverage decisions in the absence of a national Medicare policy.
- Total Non-Facility RVU values and Total Facility RVU values are identical.
Multiple Procedure (Modifier 51):
- Multiple Procedure (Modifier 51): All primary codes for harvest, preparation, and application have a "2" indicator, meaning standard multiple procedure payment adjustment rules apply.
- A 50% payment reduction applies when these procedures are performed with other procedures in the same operative session.
Bilateral Surgery Modifier (50):
- These procedures have a bilateral indicator of "0" and cannot be reported as bilateral procedures.
Assistant at Surgery Modifier (80, 81, 82, or AS):
- Payment restrictions for assistants at surgery do not apply to this procedure.
- An assistant surgeon may be paid.
OCE Guidelines:
- This ‘integrated’ OCE (IOCE) program processes claims for outpatient institutional providers, including hospitals that are subject to the Outpatient Prospective Payment System (OPPS).
OCE Status Indicator:
- These services have an OPPS status indicator of “C” in the OPPS Addendum B.
- Status Indicator C: Inpatient-only procedure not paid under OPPS.
- There is no payment under OPPS for services designated by CMS as "inpatient-only”.
Conclusion:
- Starting January 1, 2025, the American Medical Association (AMA) will implement new Current Procedural Terminology (CPT) codes for the excision and destruction of intra-abdominal tumors.
- These updated codes are intended to more accurately capture the complexity of the procedure by factoring in the total length of all tumors removed, rather than just the largest tumor.
- This change ensures that the coding aligns with the full scope of the procedure, helping to secure appropriate reimbursement.
References:
- AMA CPT manual 2025.
- American College of Surgeons
- CMS MPFS fee schedule 2025.
- Integrated OCE (IOCE) CMS Specifications V26.0.
- Addendum EE -- Surgical Procedures to be Excluded from Payment in ASCs for CY 2025.
